Adult Former Dependent Life Monthly Premium Schedule

ADULT FORMER DEPENDENT LIFE PREMIUM/COVERAGE (MALES-NON TOBACCO USER)

	$50,000	$100,000	$150,000	$200,000	$250,000
20-29	$6.88	$10.83	$15.00	$19.17	$23.33
30-34	$7.50	$12.08	$16.88	$21.67	$26.46
35-39	$8.75	$13.75	$19.38	$25.00	$30.63
40-44	$11.46	$19.17	$27.50	$35.83	$44.17
45-49	$16.67	$30.42	$44.38	$58.33	$72.29
50-54	$20.83	$36.25	$53.13	$70.00	$86.88
55-59	$25.00	$48.75	$71.88	$95.00	$118.13
60-64	$39.17	$75.83	$112.50	$149.17	$185.83
65-69	$62.50	$122.08	$181.88	$241.67	$301.46

ADULT FORMER DEPENDENT LIFE PREMIUM/COVERAGE (MALES-TOBACCO USER)

	$50,000	$100,000	$150,000	$200,000	$250,000
20-29	$13.76	$21.66	$30.00	$38.34	$46.66
30-34	$15.00	$24.16	$33.76	$43.34	$52.92
35-39	$17.50	$27.50	$38.76	$50.00	$61.26
40-44	$22.92	$38.34	$55.00	$71.66	$88.34
45-49	$33.34	$60.84	$88.76	$116.66	$144.58
50-54	$41.66	$72.50	$106.26	$140.00	$173.76
55-59	$50.00	$97.50	$143.76	$190.00	$236.26
60-64	$78.34	$151.66	$225.00	$298.34	$371.66
65-69	$125.00	$244.16	$363.76	$483.34	$602.92

ADULT FORMER DEPENDENT LIFE PREMIUM/COVERAGE (FEMALES-NON TOBACCO USER)

	$50,000	$100,000	$150,000	$200,000	$250,000
20-29	$5.21	$8.33	$11.25	$14.17	$17.08
30-34	$6.04	$10.00	$13.75	$17.50	$21.25
35-39	$7.50	$11.25	$15.63	$20.00	$24.38
40-44	$10.21	$17.92	$25.63	$33.33	$41.04
45-49	$12.29	$20.83	$30.00	$39.17	$48.33
50-54	$14.17	$25.00	$36.25	$47.50	$58.75
55-59	$20.83	$37.92	$55.63	$73.33	$91.04
60-64	$35.00	$66.67	$98.75	$130.83	$162.92
65-69	$51.04	$98.75	$146.88	$195.00	$243.13

ADULT FORMER DEPENDENT LIFE PREMIUM/COVERAGE (FEMALES-TOBACCO USER)

	$50,000	$100,000	$150,000	$200,000	$250,000
20-29	$10.42	$16.66	$22.50	$28.34	$34.16
30-34	$12.08	$20.00	$27.50	$35.00	$42.50
35-39	$15.00	$22.50	$31.26	$40.00	$48.76
40-44	$20.42	$35.84	$51.26	$66.66	$82.08
45-49	$24.58	$41.66	$60.00	$78.34	$96.66
50-54	$28.34	$50.00	$72.50	$95.00	$117.50
55-59	$41.66	$75.84	$111.26	$146.66	$182.08
60-64	$70.00	$133.34	$197.50	$261.66	$325.84
65-69	$102.08	$197.50	$293.76	$390.00	$486.26